Letters to the Editor
Carpal Arthritis as the Initial Manifestation of Gitelman's Syndrome
Artritis de carpos como debut en un síndrome de Gitelman
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It maintains a close similarity with Bartter syndrome but unlike the latter hypomagnesemia and hypocalciuria are also persistent. The fundamental change lies in the Na<span class="elsevierStyleSup">+</span>/Cl<span class="elsevierStyleSup">−</span> cotransporter sensitive to thiazides in the distal tubule.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 43-year-old male with no personal or family history, referred to the outpatient clinics from the hospital emergency room after presenting an acute episode of arthritis of both wrists treated for a few days with low dose corticosteroids. The patient had no previous injuries or infectious symptomatology.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The study of rheumatoid factor and autoantibodies (ANA, ENA, antiCCP) and the serology for human immunodeficiency virus and hepatitis B and C were negative. The acute phase reactants were in the normal range. Radiological examination showed mild degenerative signs of the right third metacarpophalangeal joint with no detectable calcification in the carpal triangular ligament, the symphysis pubis or knees. Incidental findings were a low serum potassium (2.1<span class="elsevierStyleHsp" style=""></span>mEq/l) and magnesium (1.4<span class="elsevierStyleHsp" style=""></span>mg/dl).</p><p id="par0020" class="elsevierStylePara elsevierViewall">After study for an electrolyte disorder by the nephrology department, he was diagnosed with Gitelman's syndrome. He was prescribed chronic oral supplements of potassium and magnesium and potassium-sparing diuretics, spironolactone initially, which had to be replaced by epleronone after developing gynecomastia.</p><p id="par0025" class="elsevierStylePara elsevierViewall">It is well known that magnesium is a cofactor of many pyrophosphatases and plasma levels have been associated with calcium pyrophosphate crystal arthropathy. In cases of hypomagnesemia, it alters the solubility of calcium pyrophosphatase leading to precipitation of crystals at the joint level and producing pseudogout.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In Gitelman's syndrome there is an increased elimination of magnesium via the kidneys which is not easy to correct. This is because high oral doses usually result in episodes of diarrhea that favor its loss via the gut. In addition, higher intake also correlate with greater urinary losses.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Our patient had several episodes of arthritis of the wrists despite optimal medical therapy, usually coinciding with periods when plasma magnesium levels were lower. This, together with the absence of other causes explaining the presence of self-limited arthritis, suggests that we find ourselves with a rare form of calcium pyrophosphate crystal arthritis. Although we must emphasize that in this case the diagnosis of the disease is not definitive, we did not analyze the joint fluid for crystals and have not found characteristic<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> radiological signs.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Martínez Tomàs A, et al. Artritis de carpos como debut en un síndrome de Gitelman. Reumatol Clin. 2012;<span class="elsevierStyleBold">8</span>:158–61.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Parestesias como manifestación inicial del síndrome de Gitelman" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.M. Machín-Lázaro" 1 => "L. Sánchez-Martínez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Med Clin (Barc)" "fecha" => "2005" "volumen" => "125" "paginaInicial" => "635" "paginaFinal" => "639" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Condrocalcinosis e hipomagnesemia: evolución clinicorradiológica" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J. González Domínguez" 1 => "A. Escudero Contreras" 2 => "V. Pérez Guijo" 3 => "F.G. Martínez Sánchez" 4 => "M.A. Caracuel Ruiz" 5 => "E. Collantes Estévez" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S1699-258X(08)71794-7" "Revista" => array:6 [ "tituloSerie" => "Reumatol Clin" "fecha" => "2008" "volumen" => "4" "paginaInicial" => "37" "paginaFinal" => "39" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21794493" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Alcalosis metabólica hipopotasémica: a propósito de un síndrome de Gitelman" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M.J. Puchades" 1 => "M.A. González Rico" 2 => "S. Pons" 3 => "A. Miguel" 4 => "B. Bonilla" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:8 [ "tituloSerie" => "Nefrología" "fecha" => "2004" "volumen" => "24" "numero" => "Suppl. III" "paginaInicial" => "72" "paginaFinal" => "75" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15219074" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S001650850701298X" "estado" => "S300" "issn" => "00165085" ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Fernández Dapica MP. Artropatía por cristales de pirofosfato cálcico. Otras artropatías microcristalinas. In: Sociedad Española de Reumatología. Manual SER de las Enfermedades Reumáticas. Buenos Aires; Madrid; 2008 [Editorial Médica Panamericana. p. 344–51]." ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735743/0000000800000003/v1_201305061639/S2173574312000342/v1_201305061639/en/main.assets" "Apartado" => array:4 [ "identificador" => "8400" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735743/0000000800000003/v1_201305061639/S2173574312000342/v1_201305061639/en/main.pdf?idApp=UINPBA00004M&text.app=https://reumatologiaclinica.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574312000342?idApp=UINPBA00004M" ]
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