Images in Clinical Rheumatology
Recurrent Stress Fractures in the Feet of a Patient Treated With Antiretrovirals
Fracturas de fatiga de repetición en pies en un paciente tratado con antirretrovirales
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(B) Sagittal MRI of left foot in short tau inversion recovery (STIR) sequence showing bone edema in diaphysis of the second metatarsal, and in neighboring soft tissue. (C) Plain radiography showing the image of the fracture callus in the diaphysis of the second metatarsal of left foot.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Patients with human immunodeficiency virus (HIV) develop bone complications attributable to both the presence of the virus and to the secondary effects of certain antiretroviral drugs. The clinical forms of bone involvement are osteonecrosis, even polyarticular,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> osteoporosis and osteomalacia.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> These last 2 entities are associated with a high risk of fracture.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> Stress fractures have been reported in HIV patients<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> and, to a greater extent, in HIV patients treated with tenofovir.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a male HIV-positive patient (diagnosed in 1999), who began antiretroviral therapy with the following regimen. From September 1999 to November of the same year, he took stavudine (d4T) plus didanosine (ddi) and nelfinavir. In November, he changed to zidovudine (AZT) plus lamivudine (3TC) and nevirapine, which he maintains until July 2008, when he began with emtricitabine, plus tenofovir, as well as nevirapine, until the present time. In 2011, he came to the rheumatology clinic with a 2-month history of pain in the dorsum of his right foot, with no previous injury. He underwent bone scintigraphy using Tc-99m, which revealed a severe trauma in the naviculocuneiform region of the right tarsus and a focal lesion of the third metatarsal bone of the right foot, suggestive of a stress fracture (last densitometry, <span class="elsevierStyleItalic">T</span>-score in femur: −2.3 standard deviations [SD]; <span class="elsevierStyleItalic">T</span>-score in spine: −2.4 SD) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). Magnetic resonance imaging (MRI) showed a clear signal alteration in midfoot, which was manifested as a somewhat lower signal intensity in T1 and an increase in short tau inversion recovery (STIR) sequences, with a discreetly higher signal intensity at the base of the third metatarsal bone. The suggested diagnosis was a stress fracture of right midfoot affecting the naviculocuneiform joint, at the cuboid and third metatarsal bone of the right foot (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). He was treated with nonsteroidal anti-inflammatory drugs (NSAID) and rest. Three months later, the fracture had healed without side effects. In 2012, after an overexertion, the patient presented with mechanical pain in the region of the metatarsus of the left foot. As another stress fracture was suspected, he underwent MRI, which revealed bone edema in the diaphysis of the second metatarsal bone, and in the neighboring soft tissue, consistent with a stress fracture of the second metatarsal bone of the left foot (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A and B). He was treated with rest and conservative measures and, the symptoms disappeared in 2 months (plain radiography showed an image of a fracture callus in the diaphysis of the second metatarsal of the left foot (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>C). On the 30th of January of 2014, the patient returned to the rheumatology clinic, with an increase in the volume of right ankle after another overexertion (a simple walk). Given the possibility of another fracture, he was studied by MRI, which showed a linear image at the level of the talar head, adjacent to the talonavicular joint. He also had a subchondral lesion at the level of the talus (talonavicular joint) with an irregular increase in the talus (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>A and B).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">With a diagnosis that suggested stress fracture of the right talus, the patient was treated with complete rest, the use of 2 crutches, and painkillers. After 3 months, his clinical improvement was complete. The improvement was observed in a new MRI.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical Disclosures</span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Protection of human and animal subjects</span><p id="par0020" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Confidentiality of data</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Right to privacy and informed consent</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of Interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:3 [ "identificador" => "sec0005" "titulo" => "Ethical Disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0015" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0020" "titulo" => "Right to privacy and informed consent" ] ] ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of Interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-08-05" "fechaAceptado" => "2015-11-25" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Campillo MÁ, Salman Monte TC, Ciria M, Ares J. Fracturas de fatiga de repetición en pies en un paciente tratado con antirretrovirales. Reumatol Clin. 2017;13:50–52.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 585 "Ancho" => 1600 "Tamanyo" => 113750 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Bone scintigraphy using <span class="elsevierStyleSup">99m</span>Tc, which reveals a severe lesion in the naviculocuneiform region of right tarsus. (B) Sagittal magnetic resonance imaging in short tau inversion recovery (STIR) sequences with an increased signal intensity. More evident at the intermediate cuneiform level and right lateral region.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 674 "Ancho" => 2000 "Tamanyo" => 143359 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A) Coronal magnetic resonance imaging (MRI), with fat saturation, showing bone edema in diaphysis of the second metatarsal of left foot, and in neighboring soft tissue. (B) Sagittal MRI of left foot in short tau inversion recovery (STIR) sequence showing bone edema in diaphysis of the second metatarsal, and in neighboring soft tissue. (C) Plain radiography showing the image of the fracture callus in the diaphysis of the second metatarsal of left foot.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 744 "Ancho" => 1500 "Tamanyo" => 151872 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Sagittal magnetic resonance imaging (MRI) in T1-weighted sequence, showing the focal lesion at the level of the talar head with diffuse edema in other bones of right foot. (B) Axial MRI of the foot in T2-weighted sequence, with fat saturation, showing focal lesion at level of the talar head and joint effusion at the level of anterior and posterior tibiotalar joint of right foot.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0025" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "[Epub ahead of print]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hypophosphatemic osteomalacia induced by tenofovir in HIV-infected patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L. Mateo" 1 => "S. Holgado" 2 => "M.L. Mariñoso" 3 => "R. Pérez-Andrés" 4 => "A. Bonjoch" 5 => "J. Romeu" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "Clin Rheumatol" "fecha" => "2014" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0030" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Endocrine complications of human immunodeficiency virus infection: hypogonadism, bone disease and tenofovir-related toxicity" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A.G. Cotter" 1 => "W.G. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 16 | 13 | 29 |
| 2024 October | 48 | 23 | 71 |
| 2024 September | 76 | 18 | 94 |
| 2024 August | 67 | 36 | 103 |
| 2024 July | 51 | 29 | 80 |
| 2024 June | 59 | 33 | 92 |
| 2024 May | 53 | 35 | 88 |
| 2024 April | 64 | 31 | 95 |
| 2024 March | 66 | 26 | 92 |
| 2024 February | 48 | 20 | 68 |
| 2024 January | 49 | 13 | 62 |
| 2023 December | 44 | 24 | 68 |
| 2023 November | 57 | 21 | 78 |
| 2023 October | 60 | 22 | 82 |
| 2023 September | 92 | 33 | 125 |
| 2023 August | 47 | 15 | 62 |
| 2023 July | 64 | 23 | 87 |
| 2023 June | 64 | 18 | 82 |
| 2023 May | 71 | 20 | 91 |
| 2023 April | 46 | 13 | 59 |
| 2023 March | 68 | 30 | 98 |
| 2023 February | 55 | 27 | 82 |
| 2023 January | 69 | 34 | 103 |
| 2022 December | 68 | 35 | 103 |
| 2022 November | 63 | 26 | 89 |
| 2022 October | 79 | 29 | 108 |
| 2022 September | 53 | 74 | 127 |
| 2022 August | 51 | 40 | 91 |
| 2022 July | 37 | 42 | 79 |
| 2022 June | 56 | 28 | 84 |
| 2022 May | 63 | 39 | 102 |
| 2022 April | 36 | 40 | 76 |
| 2022 March | 38 | 38 | 76 |
| 2022 February | 59 | 28 | 87 |
| 2022 January | 64 | 35 | 99 |
| 2021 December | 36 | 38 | 74 |
| 2021 November | 42 | 51 | 93 |
| 2021 October | 53 | 59 | 112 |
| 2021 September | 51 | 34 | 85 |
| 2021 August | 30 | 32 | 62 |
| 2021 July | 30 | 26 | 56 |
| 2021 June | 37 | 28 | 65 |
| 2021 May | 47 | 45 | 92 |
| 2021 April | 77 | 77 | 154 |
| 2021 March | 43 | 35 | 78 |
| 2021 February | 36 | 23 | 59 |
| 2021 January | 22 | 14 | 36 |
| 2020 December | 24 | 27 | 51 |
| 2020 November | 27 | 12 | 39 |
| 2020 October | 17 | 19 | 36 |
| 2020 September | 38 | 27 | 65 |
| 2020 August | 19 | 20 | 39 |
| 2020 July | 14 | 17 | 31 |
| 2020 June | 28 | 33 | 61 |
| 2020 May | 16 | 17 | 33 |
| 2020 April | 20 | 15 | 35 |
| 2020 March | 18 | 2 | 20 |
| 2020 February | 1 | 0 | 1 |
| 2019 May | 3 | 0 | 3 |
| 2019 April | 1 | 0 | 1 |
| 2019 January | 2 | 0 | 2 |
| 2018 December | 2 | 0 | 2 |
| 2018 October | 1 | 0 | 1 |
| 2018 May | 6 | 0 | 6 |
| 2018 April | 65 | 4 | 69 |
| 2018 March | 75 | 7 | 82 |
| 2018 February | 67 | 4 | 71 |
| 2018 January | 69 | 3 | 72 |
| 2017 December | 40 | 11 | 51 |
| 2017 November | 47 | 5 | 52 |
| 2017 October | 29 | 5 | 34 |
| 2017 September | 36 | 7 | 43 |
| 2017 August | 21 | 7 | 28 |
| 2017 July | 32 | 14 | 46 |
| 2017 June | 43 | 11 | 54 |
| 2017 May | 53 | 16 | 69 |
| 2017 April | 45 | 39 | 84 |
| 2017 March | 56 | 17 | 73 |
| 2017 February | 31 | 20 | 51 |
| 2017 January | 6 | 10 | 16 |
| 2016 December | 6 | 15 | 21 |
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