The leopard woman: a subacute and rare presentation

The leopard woman: a subacute and rare presentation Martin Bergman and Amy Lundholm disease-modifying antirheumatic drugs. Am J Med Sci population-based cohort study. Arthritis Res Ther 2010;340:28290. 2014;16:418. 105 Martindale J, Smith J, Sutton CJ et al. Disease and 108 Shen B, Zhang A, Liu J et al. Body image disturbance psychological status in ankylosing spondylitis. and quality of life in Chinese patients with ankylosing Rheumatology 2006;45:128893. spondylitis. Psychol Psychother 2014;87:32437. 106 Kilic G, Kilic E, Ozgocmen S. Relationship between 109 Katon W, Ciechanowski P. Impact of major depression on psychiatric status, self-reported outcome measures, and chronic medical illness. J Psychosom Res 2002;53:85963. clinical parameters in axial spondyloarthritis. Medicine 110 Ozgul A, Peker F, Taskaynatan MA et al. Effect of 2014;93:e337. ankylosing spondylitis on health-related quality of life 107 Meesters JJ, Bremander A, Bergman S et al. The risk for and different aspects of social life in young patients. Clin depression in patients with ankylosing spondylitis: a Rheumatol 2006;25:16874. Rheumatology 2018;57:428 doi:10.1093/rheumatology/kex311 Clinical vignette Advance Access publication 11 August 2017 The leopard woman: a subacute and rare FIG.1 PET scan showing multifocal hypermetabolic activity presentation in a patient with sarcoid myositis A 43-year-old woman presented with a 9-month history of painful swelling of the left forearm, with no previous trauma. Personal and family histories were unremarkable. On examination, a tender nodule was identified on the radial aspect of the forearm, without other relevant findings. US revealed muscle hypertrophy of the entire forearm, which was confirmed by MRI (T1T2 hypersignal), sug- gesting myositis. Laboratory tests showed elevated acute phase reactants (ESR and CRP) and serum angio- tensin-converting enzyme; serum muscle enzymes were normal. Muscle biopsy identified granulomatous myositis with epithelioid sarcoid granulomata. Chest CT scan revealed a micronodular pulmonary pat- tern; pulmonary function tests were normal. Brochoaveolar lavage showed a CD4:CD8 ratio of 5.1 and 48% lympho- cytes. A 2-deoxy-2-[fluorine-18]fluoro-D-glucose ( F-FDG) PET/CT scan identified multifocal myositis with hypermeta- bolic activity, resulting in a leopard appearance (Fig. 1). The diagnosis of nodular-type muscular sarcoidosis was established. Corticosteroid therapy (1 mg/kg/day) was started, with good clinical, laboratory and imaging outcomes in approximately 6 weeks. Sarcoidosis is a granulomatous multisystem disorder of unknown aetiology. The lungs are commonly affected, al- though it can also involve the musculoskeletal system, albeit less frequently. There are three types of muscular sarcoidosis: acute myopathy, chronic and nodular. Asymptomatic myopathy may occur in 5080% of pa- tients, whereas clinical symptoms are present in< 5% [1]. Funding: No specific funding was received from any bodies in the public, commercial or not-for-profit sectors F-FDG PET scan in maximum intensity projection, in the to carry out the work described in this manuscript. coronal plane, showing multifocal linear and nodular pathological uptake of FDG, diffusely distributed along the Disclosure statement: The authors have declared no bundles of the skeletal striated muscles, mimicking the conflicts of interest. pattern of a leopard. 1 1 ´ ´ ´ Gisela Eugenio , Jose Antonio Pereira da Silva ´ 2 direito, 3030-482 Coimbra, Portugal. and Catia Duarte E-mail: giselaeugenio@gmail.com Rheumatology Department, Centro Hospitalar e Universita´ rio de Coimbra, Coimbra, Portugal Reference Correspondence to: Gisela Sofia dos Santos Euge ´ nio, Department of Rheumatology, Centro Hospitalar e Universi- 1 Rao DA, Dellaripa PF. Extrapulmonary manifestations of ta ´ rio de Coimbra, Rua Engenheiro Jorge Anjinho, lote 4, sarcoidosis. Rheum Dis Clin North Am 2013;39:27797. The Author 2017. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oup.com 428 https://academic.oup.com/rheumatology Downloaded from https://academic.oup.com/rheumatology/article-abstract/57/3/428/4080842 by Ed 'DeepDyve' Gillespie user on 22 March 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Rheumatology Oxford University Press

The leopard woman: a subacute and rare presentation

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Oxford University Press
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© The Author 2017. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oup.com
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1462-0324
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10.1093/rheumatology/kex311
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Abstract

Martin Bergman and Amy Lundholm disease-modifying antirheumatic drugs. Am J Med Sci population-based cohort study. Arthritis Res Ther 2010;340:28290. 2014;16:418. 105 Martindale J, Smith J, Sutton CJ et al. Disease and 108 Shen B, Zhang A, Liu J et al. Body image disturbance psychological status in ankylosing spondylitis. and quality of life in Chinese patients with ankylosing Rheumatology 2006;45:128893. spondylitis. Psychol Psychother 2014;87:32437. 106 Kilic G, Kilic E, Ozgocmen S. Relationship between 109 Katon W, Ciechanowski P. Impact of major depression on psychiatric status, self-reported outcome measures, and chronic medical illness. J Psychosom Res 2002;53:85963. clinical parameters in axial spondyloarthritis. Medicine 110 Ozgul A, Peker F, Taskaynatan MA et al. Effect of 2014;93:e337. ankylosing spondylitis on health-related quality of life 107 Meesters JJ, Bremander A, Bergman S et al. The risk for and different aspects of social life in young patients. Clin depression in patients with ankylosing spondylitis: a Rheumatol 2006;25:16874. Rheumatology 2018;57:428 doi:10.1093/rheumatology/kex311 Clinical vignette Advance Access publication 11 August 2017 The leopard woman: a subacute and rare FIG.1 PET scan showing multifocal hypermetabolic activity presentation in a patient with sarcoid myositis A 43-year-old woman presented with a 9-month history of painful swelling of the left forearm, with no previous trauma. Personal and family histories were unremarkable. On examination, a tender nodule was identified on the radial aspect of the forearm, without other relevant findings. US revealed muscle hypertrophy of the entire forearm, which was confirmed by MRI (T1T2 hypersignal), sug- gesting myositis. Laboratory tests showed elevated acute phase reactants (ESR and CRP) and serum angio- tensin-converting enzyme; serum muscle enzymes were normal. Muscle biopsy identified granulomatous myositis with epithelioid sarcoid granulomata. Chest CT scan revealed a micronodular pulmonary pat- tern; pulmonary function tests were normal. Brochoaveolar lavage showed a CD4:CD8 ratio of 5.1 and 48% lympho- cytes. A 2-deoxy-2-[fluorine-18]fluoro-D-glucose ( F-FDG) PET/CT scan identified multifocal myositis with hypermeta- bolic activity, resulting in a leopard appearance (Fig. 1). The diagnosis of nodular-type muscular sarcoidosis was established. Corticosteroid therapy (1 mg/kg/day) was started, with good clinical, laboratory and imaging outcomes in approximately 6 weeks. Sarcoidosis is a granulomatous multisystem disorder of unknown aetiology. The lungs are commonly affected, al- though it can also involve the musculoskeletal system, albeit less frequently. There are three types of muscular sarcoidosis: acute myopathy, chronic and nodular. Asymptomatic myopathy may occur in 5080% of pa- tients, whereas clinical symptoms are present in< 5% [1]. Funding: No specific funding was received from any bodies in the public, commercial or not-for-profit sectors F-FDG PET scan in maximum intensity projection, in the to carry out the work described in this manuscript. coronal plane, showing multifocal linear and nodular pathological uptake of FDG, diffusely distributed along the Disclosure statement: The authors have declared no bundles of the skeletal striated muscles, mimicking the conflicts of interest. pattern of a leopard. 1 1 ´ ´ ´ Gisela Eugenio , Jose Antonio Pereira da Silva ´ 2 direito, 3030-482 Coimbra, Portugal. and Catia Duarte E-mail: giselaeugenio@gmail.com Rheumatology Department, Centro Hospitalar e Universita´ rio de Coimbra, Coimbra, Portugal Reference Correspondence to: Gisela Sofia dos Santos Euge ´ nio, Department of Rheumatology, Centro Hospitalar e Universi- 1 Rao DA, Dellaripa PF. Extrapulmonary manifestations of ta ´ rio de Coimbra, Rua Engenheiro Jorge Anjinho, lote 4, sarcoidosis. Rheum Dis Clin North Am 2013;39:27797. The Author 2017. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oup.com 428 https://academic.oup.com/rheumatology Downloaded from https://academic.oup.com/rheumatology/article-abstract/57/3/428/4080842 by Ed 'DeepDyve' Gillespie user on 22 March 2018

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RheumatologyOxford University Press

Published: Mar 1, 2018

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