Images in Clinical Rheumatology
Fever, Palmoplantar Pustules and Oligoarthritis in a Young Woman
Fiebre, lesiones vesículo-ampollosas y oligoartritis en una paciente joven
Francisco Gallo Puelles
, Manuel José Moreno Ramos, María José Diaz Navarro, Manuel Castaño Sánchez
Corresponding author
Servicio de Reumatología, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
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María José Diaz Navarro, Manuel Castaño Sánchez" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Francisco" "apellidos" => "Gallo Puelles" "email" => array:1 [ 0 => "fgallopuelles@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Manuel José" "apellidos" => "Moreno Ramos" ] 2 => array:2 [ "nombre" => "María José" "apellidos" => "Diaz Navarro" ] 3 => array:2 [ "nombre" => "Manuel" "apellidos" => "Castaño Sánchez" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Reumatología, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fiebre, lesiones vesículo-ampollosas y oligoartritis en una paciente joven" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 601 "Ancho" => 800 "Tamanyo" => 86233 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Diffuse pustular lesions on the dorsum of the hands.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case Report</span><p id="par0005" class="elsevierStylePara elsevierViewall">The patient was a 41-year-old woman, with no other remarkable findings of interest. She presented with a 3-week history of fever, arthralgia, swollen neck and pustular lesions on her hands, accompanied by pain. Over the last few days, she reported parasternal swelling that also affected right shoulder.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Physical exploration revealed erythema and edema in neck, glenohumeral and right sternoclavicular arthritis, and diffuse dorsopalmar pustular lesions on her hands (up to 2<span class="elsevierStyleHsp" style=""></span>mm) (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1–3</a>), outer ear (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>) and neck and back (with acne). We found no other signs or lymphadenopathy.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Diagnosis/disease Course</span><p id="par0010" class="elsevierStylePara elsevierViewall">Laboratory findings: leukocytosis 13,000 (normal: 10,020); platelets 68,000; C-reactive protein (CRP) 14.7 (<<span class="elsevierStyleHsp" style=""></span>0.5<span class="elsevierStyleHsp" style=""></span>mg/dL); and erythrocyte sedimentation rate 20<span class="elsevierStyleHsp" style=""></span>mm/1st hour. Moreover, antinuclear antibodies, anti-DNA antibodies, antineutrophil cytoplasmic antibodies, anti-extractable nuclear antigen antibodies, angiotensin-converting enzyme, rheumatoid factor, anti-cyclic citrullinated peptide antibodies, immunoglobulins, complement and TSH/free T4 were normal. Mantoux and serology (hepatitis B and C viruses, human immunodeficiency virus, syphilis) and cultures were negative (blood culture, urine culture, exudates from pharynx, urethra and pustules).<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2–4</span></a> Neck and abdominal ultrasound and chest and shoulder radiographs provided no useful evidence. Biopsy of the skin lesions: compatible with palmoplantar pustulosis. Bone scintigraphy: increased symmetrical uptake in sternoclavicular “bull's head”, compatible with synovitis, acne, pustulosis, hyperostosis and osteitis (SAPHO) (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). Treatment was begun with nonsteroidal anti-inflammatory drugs, systemic (16<span class="elsevierStyleHsp" style=""></span>mg oral methylprednisolone) and topical (betamethasone-gentamycin ointment) corticosteroids. The fever, joint involvement and skin lesions remitted (scaling; <a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>), and the analytical findings were normalized (previous CRP, leukocytosis and thrombocytopenia). Once corticosteroid therapy had been reduced, methotrexate was begun with a rapid dose escalation, and the response was positive and tolerance was good.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,3,5,6</span></a></p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">The SAPHO syndrome is an uncommon disorder of unknown etiology, that affects young men and women in a similar distribution.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6,7</span></a> Most authors classify it under the spondyloarthritides, although it could be a reactive arthropathy secondary to an infection by an agent with a low virulence.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,4,7,8</span></a> On occasion, it may prove difficult to diagnose because it overlaps with other infectious conditions that present with fever and skin lesions.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8,9</span></a> The presence of edema in neck and chest, acne and oligoarthritis, in the absence of bacteriological isolation, leads us to suspect an autoimmune etiology.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> The skin biopsy and scintigraphic data subsequently confirmed our presumed diagnosis.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Ethical Disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Protection of human and animal subjects</span><p id="par0020" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association (Declaration of Helsinki).</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">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="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">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="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">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:6 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case Report" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Diagnosis/disease Course" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 3 => array:3 [ "identificador" => "sec0020" "titulo" => "Ethical Disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Right to privacy and informed consent" ] ] ] 4 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of Interest" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-11-10" "fechaAceptado" => "2016-01-12" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Gallo Puelles F, Moreno Ramos MJ, Diaz Navarro MJ, Castaño Sánchez M. Fiebre, lesiones vesículo-ampollosas y oligoartritis en una paciente joven. 2017;13:115–117.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 584 "Ancho" => 1040 "Tamanyo" => 97396 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Diffuse pustular lesions on the dorsum of the hands.</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" => 601 "Ancho" => 800 "Tamanyo" => 86233 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Diffuse pustular lesions on the dorsum of the hands.</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" => 584 "Ancho" => 1040 "Tamanyo" => 102206 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Diffuse pustular lesions on the palms of the hands.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1066 "Ancho" => 800 "Tamanyo" => 84439 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Pustular lesion on right outer ear.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 2261 "Ancho" => 1632 "Tamanyo" => 410697 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Resolution of pustular lesions on the palms of the hands (scaling phase).</p>" ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Fig. 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 1313 "Ancho" => 1600 "Tamanyo" => 119881 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Bone scintigraphy with typical sternoclavicular uptake of the so-called “bull's head”, compatible with synovitis, acne, pustulosis, hyperostosis and osteitis (SAPHO) syndrome.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Case of SAPHO syndrome with significant sternocostoclavicular hyperostosis [Article in Japanese]" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "F. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 29 | 10 | 39 |
| 2024 September | 68 | 22 | 90 |
| 2024 August | 88 | 44 | 132 |
| 2024 July | 66 | 32 | 98 |
| 2024 June | 82 | 40 | 122 |
| 2024 May | 94 | 34 | 128 |
| 2024 April | 95 | 29 | 124 |
| 2024 March | 89 | 47 | 136 |
| 2024 February | 74 | 33 | 107 |
| 2024 January | 75 | 24 | 99 |
| 2023 December | 53 | 18 | 71 |
| 2023 November | 67 | 36 | 103 |
| 2023 October | 87 | 30 | 117 |
| 2023 September | 88 | 36 | 124 |
| 2023 August | 107 | 16 | 123 |
| 2023 July | 106 | 22 | 128 |
| 2023 June | 86 | 21 | 107 |
| 2023 May | 77 | 24 | 101 |
| 2023 April | 72 | 9 | 81 |
| 2023 March | 95 | 34 | 129 |
| 2023 February | 76 | 35 | 111 |
| 2023 January | 67 | 21 | 88 |
| 2022 December | 78 | 30 | 108 |
| 2022 November | 88 | 24 | 112 |
| 2022 October | 94 | 40 | 134 |
| 2022 September | 67 | 37 | 104 |
| 2022 August | 65 | 62 | 127 |
| 2022 July | 83 | 68 | 151 |
| 2022 June | 77 | 37 | 114 |
| 2022 May | 70 | 40 | 110 |
| 2022 April | 77 | 54 | 131 |
| 2022 March | 99 | 44 | 143 |
| 2022 February | 88 | 37 | 125 |
| 2022 January | 73 | 38 | 111 |
| 2021 December | 52 | 37 | 89 |
| 2021 November | 60 | 39 | 99 |
| 2021 October | 86 | 68 | 154 |
| 2021 September | 59 | 44 | 103 |
| 2021 August | 51 | 49 | 100 |
| 2021 July | 61 | 28 | 89 |
| 2021 June | 71 | 34 | 105 |
| 2021 May | 71 | 65 | 136 |
| 2021 April | 170 | 97 | 267 |
| 2021 March | 85 | 34 | 119 |
| 2021 February | 54 | 31 | 85 |
| 2021 January | 60 | 30 | 90 |
| 2020 December | 59 | 29 | 88 |
| 2020 November | 66 | 25 | 91 |
| 2020 October | 64 | 20 | 84 |
| 2020 September | 64 | 35 | 99 |
| 2020 August | 39 | 21 | 60 |
| 2020 July | 35 | 23 | 58 |
| 2020 June | 42 | 24 | 66 |
| 2020 May | 45 | 20 | 65 |
| 2020 April | 26 | 21 | 47 |
| 2020 March | 21 | 2 | 23 |
| 2020 February | 12 | 0 | 12 |
| 2020 January | 5 | 0 | 5 |
| 2019 December | 7 | 0 | 7 |
| 2019 November | 5 | 0 | 5 |
| 2019 October | 6 | 0 | 6 |
| 2019 September | 9 | 0 | 9 |
| 2019 August | 3 | 0 | 3 |
| 2019 July | 12 | 0 | 12 |
| 2019 June | 33 | 0 | 33 |
| 2019 May | 54 | 0 | 54 |
| 2019 April | 2 | 0 | 2 |
| 2019 March | 4 | 0 | 4 |
| 2019 February | 2 | 0 | 2 |
| 2019 January | 5 | 0 | 5 |
| 2018 December | 19 | 0 | 19 |
| 2018 May | 6 | 0 | 6 |
| 2018 April | 118 | 6 | 124 |
| 2018 March | 82 | 9 | 91 |
| 2018 February | 35 | 4 | 39 |
| 2018 January | 66 | 5 | 71 |
| 2017 December | 40 | 10 | 50 |
| 2017 November | 36 | 4 | 40 |
| 2017 October | 39 | 8 | 47 |
| 2017 September | 26 | 8 | 34 |
| 2017 August | 22 | 6 | 28 |
| 2017 July | 29 | 8 | 37 |
| 2017 June | 34 | 6 | 40 |
| 2017 May | 54 | 23 | 77 |
| 2017 April | 53 | 45 | 98 |
| 2017 March | 40 | 28 | 68 |
| 2017 February | 1 | 8 | 9 |
| 2017 January | 3 | 11 | 14 |
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