Cases reported "Synovitis"

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1/16. Do B cells influence disease progression in chronic synovitis? Lessons from primary hypogammaglobulinaemia.

    We describe a 62-yr-old male patient with primary hypogammaglobulinaemia (PH) who fulfilled the 1987 American Rheumatism association/American College of rheumatology revised diagnostic criteria for rheumatoid arthritis (RA) but, despite persistent symmetrical synovitis, did not develop erosions. virology studies and blood and synovial fluid (SF) cultures were consistently negative; a search for crystals in the SF was unrevealing. Peripheral blood (PB) B cells were absent, whilst the PB CD3( ) cell count was normal. The ratio of naive (CD45RA( )) to memory (CD45R0( )) cells was also normal (1:1) but the CD4:CD8 ratio was reversed. To our knowledge, this is the first report which combines the immunophenotypic analysis of the PB with that of the SF and synovial membrane (SM). This confirmed the absence of B cells and the reversed CD4:CD8 ratio. However, as in other chronic arthropathies, the SF and SM cellular infiltrate consisted almost exclusively of memory T cells, consistent with the preferential localization of this subset to inflamed tissues. This case indicates that synovitis can proceed persistently in the absence of B cells and that the migratory mechanisms of T cells are not altered. However, the case suggests that the absence of B cells and negativity for rheumatoid factor, combined with an increased presence of CD8( ) (suppresser/cytotoxic) T cells in the joint, might contribute to the non-erosive nature of the synovitis.
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2/16. Case of synovitis potentially caused by Dolosigranulum pigrum.

    We report a case of synovitis in a 64-year-old man who developed the infection while on steroid therapy for rheumatoid arthritis. Dolosigranulum pigrum, a gram-positive catalase-negative coccus, was isolated from two sets of blood cultures prior to antibiotic therapy. The patient was treated with 4 weeks of appropriate antibiotics, and the synovial inflammation resolved. Although synovial aspirates were never positive for any bacteria or fungi, the timing of positive blood cultures and absence of other pathogens suggest the possible etiology as D. pigrum.
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3/16. Granulomatous synovitis and osteitis caused by sporothrix schenckii.

    sporotrichosis must be considered in the differential diagnosis of granulomatous inflammation involving bones and joints. The organisms are difficult to demonstrate in direct smears and in histiologic sections, but they grow readily on routine fungal culture media. The cases of two patients, one with sporothrix arthritis and one with sporothrix arthritis and osteitis, are presented. The latter patient underwent ten surgical procedures over a period of 6 1/2 years and was treated for tuberculous arthritis without a definite diagnosis before fungal cultures were obtained and sporothrix schenckii isolated.
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4/16. Giant synovial cyst of the calf and thigh in a patient with granulomatous synovitis.

    A giant synovial cyst with granulomatous synovitis was removed from the thigh and calf in an 80-year-old woman. The lesion included necrotizing, epitheloid cell granulomata with Langhans' type giant cells. Chest X-ray, tuberculin testing, cultures for Acid Fast bacilli, as well as aerobic, anaerobic and fungal cultures were all negative. The treatment consisted of synovectomy and total knee arthroplasty with an uneventful recovery. A giant calf cyst, usually associated with rheumatoid arthritis, but in this situation, noted in granulomatous synovitis seems not to have been reported previously.
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5/16. Lyme borreliosis in portugal caused by borrelia lusitaniae? Clinical report on the first patient with a positive skin isolate.

    BACKGROUND: borrelia lusitaniae was isolated from an ixodes ricinus tick in portugal in 1993 for the first time. Further, this borrelia genospecies has been found in ixodid ticks collected around the coasts of southern portugal and North africa. Its reservoir has not been defined yet. B. lusitaniae was isolated once until now from a patient with a long standing and expanding skin disorder. PATIENT AND methods: A 46-year-old Portuguese woman presented with a skin lesion on the left thigh which had evolved slowly over ten years. The patient reported limb paraesthesias, cramps, chronic headaches, and cardiac rhythm disturbances. history of tick bites was negative nor had the patient ever noticed a skin lesion comparable with erythema chronicum migrans. skin biopsies were taken for histological evaluation, culture and dna detection. antibodies to borrelia were searched by indirect immunofluorescence assay and Western-blot. RESULTS: A bilateral carpal tunnel syndrome and local synovitis was diagnosed. Dermato-histology was normal, serology was negative. Spirochaetal organisms were cultured from a skin biopsy and identified as B. lusitaniae. The patient improved after a 2-week course of intravenous ceftriaxone; the skin lesions did not expand further. CONCLUSIONS: This culture confirmed skin infection by B. lusitaniae in a patient from portugal suggests an additional human pathogen out of the B. burgdorferi sensu lato complex in europe, particularly in portugal.
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6/16. Mycobacterial synovitis caused by slow-growing nonchromogenic species: eighteen cases and a review of the literature.

    CONTEXT: Slow-growing nonchromogenic mycobacterial species are an infrequent cause of soft tissue infection. Because these organisms are rare, they are not often initially considered in the differential diagnosis of synovitis. OBJECTIVE: To evaluate the clinical and pathologic characteristics of patients with synovitis resulting from slow-growing nonchromogenic mycobacterial species. DESIGN: A 20-year retrospective review of records from The Methodist Hospital microbiology Laboratory identified 18 culture-positive cases of synovitis that resulted from slow-growing nonchromogenic mycobacteria, including 14 caused by mycobacterium avium complex, 1 caused by Mycobacterium malmoense, 1 caused by mycobacterium haemophilum, and 2 caused by Mycobacterium nonchromogenicum isolates. In addition, a comprehensive literature search revealed an additional 48 cases of synovitis caused by slow-growing nonchromogenic mycobacteria. RESULTS: The historic literature described the majority of the 48 patients as previously healthy, elderly individuals with a several-month history of monoarticular pain and swelling in the small joints of the upper extremity. In contrast, the current series demonstrated the probable role of multiple chronic coexisting medical conditions in promoting disease susceptibility. These patients were also unique in their significantly younger age distribution and diversity of infection sites. Histologic examination and direct acid-fast bacteria stains generally did not aid the diagnosis. amputation was performed in 2 patients because of delayed identification of disease. CONCLUSIONS: The current series demonstrates that difficult identification and infrequent occurrence cause these organisms to be overlooked by physicians and laboratory personnel. A heightened clinical suspicion for slow-growing nonchromogenic mycobacterial species is necessary when routine culture and histopathologic findings do not readily isolate an organism, or when the patient does not respond to antibiotic and anti-inflammatory treatment.
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7/16. nocardia asteroides sepsis of the knee.

    nocardia asteroides as an infecting agent has been an increasingly identified pathogen in humans, especially in immunosuppressed hosts. The Nocardia organisms as a cause of septic arthritis have been very unusual and in all previously reported cases have occurred in immunosuppressed patients. This is a report of two additional patients, one of whom has had no history of immunosuppression either before infection or subsequent to treatment and resolution of the infection. The second is a case of a questionably immunosuppressed patient with nocardia asteroides septic arthritis. These cases reemphasize the importance of performing not only the most common aerobic and anaerobic bacterial cultures but also fungal and acid-fast bacilli cultures for early identification of less common organisms and for the initiation of appropriate therapy.
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8/16. The synovial fluid.

    The synovial fluid is readily available for study in all cases of effusion. Whenever a question of diagnosis arises, the fluid should be removed for study. Removal of large effusions gives temporary relief of pain. The fluid removed should be smeared on a slide, stained with hematoxylin and eosin, and plated for bacterial, viral, and fungal cultures. The solid constituents of the fluid can easily be studied in the simplest of laboratories. Most of the constituents of plasma are present in synovial fluids. Quantitation of glucose, protein, and cells and an attempt to identify crystals, cartilage fragments, or even foreign bodies are crucial to therapy and the evolution of the disease.
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9/16. Proliferative synovitis in hemophilia: biochemical and morphologic observations.

    The synovium removed from the knee of a 10-year-old with hemophilia a was characterized morphologically and biochemically. The specimen showed villous hypertrophy with hyperplasia of synovial lining cells which contained abundant intracytoplasmic granules of hemosiderin. Monolayer cultures prepared from enzymatically dispersed tissue were characterized by pigment-laden fibroblast-like cells and round cells. Both explants of synovium and adherent cells secreted a large amount of latent collagenase and neutral proteinase into the culture medium. The secretion of these enzymes dropped sharply and intracellular pigment decreased with passage of these cultures. Lysozyme was secreted by the explants but was not detected in the monolayer culture medium. These data establish the degradative potential of the synovitis found in hemophilia and support the concept that recurrent hemarthrosis without inflammation is sufficient in and of itself to produce proliferative synovitis.
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10/16. Synovial infection with mycobacterium kansasii.

    Atypical mycobacteria have been recognised as saprophytic organisms for many years, but it was only with the development of better microbiological culture techniques that they became recognised as potentially pathogenic to man. Infections of tendon sheaths and joints by these organisms may present diagnostic problems, and we report here 3 cases in which mycobacterium kansasii was responsible for disease at the hand and wrist.
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