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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The use of isotretinoin is common for the treatment of acne&#46; Patients are used to give their informed and written consent before treatment for the risk of teratogenicity&#46; However&#44; many of them are not aware of the possible skeletal side effects at long term&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Skeletal hyperostosis is rare in young patients&#46; As rheumatologists&#44; in patients with diffuse idiopathic skeletal hyperostosis we are used to ask well-known comorbidities such as obesity&#44; high blood pressure&#44; diabetes mellitus&#44; hyperinsulinemia&#44; dyslipidemia&#44; and hiperuricemia&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> However&#44; the use of isotretinoine and the cumulative doses is not always being considered&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0080" class="elsevierStylePara elsevierViewall">We describe a 36 year-old woman with intermittent periods of pain and stiffness in her cervical spine since she was 29&#46; Her past medical history was unremarkable except for the use of isotretinoin for severe acne since she was 25 years old&#46; She received 2 previous courses of isotretinoin in another center with no information about the cumulative dose&#46; However&#44; the patient reassures that she only completed the treatment in the first course&#46; In the second and in the third one&#44; as the acne resolved quickly&#44; as soon as she improved&#44; she stopped the medication on her own&#46; She came to our hospital for the third course&#46; She received 20mg of oral isotretinoin daily&#44; however she presented side effects almost inmediately &#40;nausea&#41;&#46; Therefore&#44; the dosis was lowered to 10mg daily&#46; The cumulative dose of isotretinoin in the third course was 4765 mg&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">She referred intermittent chronic cervical pain and morning stiffness of 10<span class="elsevierStyleHsp" style=""></span>min&#46; She did not refer pain at night&#44; or at other sites&#58; no pain at dorso-lumbar spine&#44; sacroiliac joints&#44; peripheral joints or entheseal symptoms&#46; No psoriasis&#44; uveitis or inflammatory bowel disease in her past medical history&#46; She was healthy and fit doing regular pilates and running&#46; She worked as a waitress&#46; She used ibuprofen 600<span class="elsevierStyleHsp" style=""></span>mg every eight hours and diazepam 5<span class="elsevierStyleHsp" style=""></span>mg at flares&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">On physical examination&#44; her weight was 50<span class="elsevierStyleHsp" style=""></span>kg&#46; She had cervical tenderness and contracture of trapezius muscles with limited rotations &#40;60&#176;&#41; at cervical spine&#46; No pain at sacroiliac joints&#44; peripheral joint or entheseal sites&#46; The neurological exploration&#44; as well as the rest of the physical examination&#44; was normal&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Laboratory findings were unremarkable&#58; erythrocyte sedimentation rate &#40;ESR&#41;&#58; 11<span class="elsevierStyleHsp" style=""></span>mm&#47;h&#59; C-reactive protein &#40;CRP&#41;&#58; 0&#46;8<span class="elsevierStyleHsp" style=""></span>mg&#47;L &#40;reference range 0&#8211;5&#41;&#44; human leucocyte antigen-B27 was negative&#59; glucose&#44; lipidic screen and uric acid were within the normal range as well as calcium&#44; phosphate&#44; alkaline phosphatase&#44; vitamin D&#44; vitamin A&#44; calcium&#44; urinary calcium&#44; thyroid and parathyroid hormone&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">She had an X-ray of her cervical spine &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Interestingly&#44; radiological progression was also observed in asymptomatic locations&#44; such as dorsal spine&#44; pelvis with mild enthesopathy at the iliac crests and right trochanter and hindfoot with signs of enthesitis at both achilles tendon insertions&#46; The echocardiogram ruled out cardiac valve calcification&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">She received ibuprofen at regular doses&#44; physiotherapy and dry needling with mild improvement of her symptoms&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">Skeletal hyperostosis is rare in young patients&#46; According to the literature&#44; the development of isotretinoin-induced skeletal hyperostosis appears 3-5 years after the treatment&#44; with cervical spine and feet being the most frequent affected areas&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Although this side effect has been described by many authors since 1983&#44;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2-9</span></a> we observe that many patients are not aware of this complication&#46; Although our report is a single case&#44; correlates with literature&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">This case report has several limitations&#46; First of all&#44; we can&#769;t give precise information about the total dosis of isotretinoin&#46; Although the maximum cumulative dose of isotretinoin ranges from 120-150mg &#47;kg &#40;safety data sheet according&#41;&#44; relapses of severe acne vulgaris are very common&#44; and for decreasing relapse rates is common to receive higher doses of isotretinoin&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">10</span></a> Our message is that this side effect can occur in daily clinical practice&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Secondly&#44; we don&#769;t have a basal cervical x- ray to compare because she didn&#769;t have cervical pain at that time&#46; She began with cervical pain at 29 years old without any previous injury&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">We wonder if the cumulative doce should be reduced or the pacient should receive more concise information about long term complications&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0065" class="elsevierStylePara elsevierViewall">In young patients with diffuse idiopathic skeletal hiperostosis&#44; 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Case Report
Diffuse idiopathic skeletal hyperostosis in a young woman treated with isotretinoin
Hiperostosis anquilosante vertebral difusa en una mujer joven tratada con isotretinoína
Monica Ibáñez Barcelóa,
Autor para correspondencia
mibanez@hsll.es

Corresponding author.
, Ana Estremera Rodrigob, Inmaculada Ros Vilamajóa, Antonio Juan Masa
a Department of Rheumatology, Hospital Son Llàtzer, Palma de Mallorca, Spain
b Department of Radiology, Hospital Son Llàtzer, Palma de Mallorca, Spain
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        "titulo" => "Hiperostosis anquilosante vertebral difusa en una mujer joven tratada con isotretino&#237;na"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">lateral cervical spine X-RAY shows ossification along the anterior aspect of the vertebral bodies from C3 to C7&#44; preservation of disc height in the involved levels and the absence of bony ankylosis of facet joints&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The use of isotretinoin is common for the treatment of acne&#46; Patients are used to give their informed and written consent before treatment for the risk of teratogenicity&#46; However&#44; many of them are not aware of the possible skeletal side effects at long term&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Skeletal hyperostosis is rare in young patients&#46; As rheumatologists&#44; in patients with diffuse idiopathic skeletal hyperostosis we are used to ask well-known comorbidities such as obesity&#44; high blood pressure&#44; diabetes mellitus&#44; hyperinsulinemia&#44; dyslipidemia&#44; and hiperuricemia&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> However&#44; the use of isotretinoine and the cumulative doses is not always being considered&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0080" class="elsevierStylePara elsevierViewall">We describe a 36 year-old woman with intermittent periods of pain and stiffness in her cervical spine since she was 29&#46; Her past medical history was unremarkable except for the use of isotretinoin for severe acne since she was 25 years old&#46; She received 2 previous courses of isotretinoin in another center with no information about the cumulative dose&#46; However&#44; the patient reassures that she only completed the treatment in the first course&#46; In the second and in the third one&#44; as the acne resolved quickly&#44; as soon as she improved&#44; she stopped the medication on her own&#46; She came to our hospital for the third course&#46; She received 20mg of oral isotretinoin daily&#44; however she presented side effects almost inmediately &#40;nausea&#41;&#46; Therefore&#44; the dosis was lowered to 10mg daily&#46; The cumulative dose of isotretinoin in the third course was 4765 mg&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">She referred intermittent chronic cervical pain and morning stiffness of 10<span class="elsevierStyleHsp" style=""></span>min&#46; She did not refer pain at night&#44; or at other sites&#58; no pain at dorso-lumbar spine&#44; sacroiliac joints&#44; peripheral joints or entheseal symptoms&#46; No psoriasis&#44; uveitis or inflammatory bowel disease in her past medical history&#46; She was healthy and fit doing regular pilates and running&#46; She worked as a waitress&#46; She used ibuprofen 600<span class="elsevierStyleHsp" style=""></span>mg every eight hours and diazepam 5<span class="elsevierStyleHsp" style=""></span>mg at flares&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">On physical examination&#44; her weight was 50<span class="elsevierStyleHsp" style=""></span>kg&#46; She had cervical tenderness and contracture of trapezius muscles with limited rotations &#40;60&#176;&#41; at cervical spine&#46; No pain at sacroiliac joints&#44; peripheral joint or entheseal sites&#46; The neurological exploration&#44; as well as the rest of the physical examination&#44; was normal&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Laboratory findings were unremarkable&#58; erythrocyte sedimentation rate &#40;ESR&#41;&#58; 11<span class="elsevierStyleHsp" style=""></span>mm&#47;h&#59; C-reactive protein &#40;CRP&#41;&#58; 0&#46;8<span class="elsevierStyleHsp" style=""></span>mg&#47;L &#40;reference range 0&#8211;5&#41;&#44; human leucocyte antigen-B27 was negative&#59; glucose&#44; lipidic screen and uric acid were within the normal range as well as calcium&#44; phosphate&#44; alkaline phosphatase&#44; vitamin D&#44; vitamin A&#44; calcium&#44; urinary calcium&#44; thyroid and parathyroid hormone&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">She had an X-ray of her cervical spine &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Interestingly&#44; radiological progression was also observed in asymptomatic locations&#44; such as dorsal spine&#44; pelvis with mild enthesopathy at the iliac crests and right trochanter and hindfoot with signs of enthesitis at both achilles tendon insertions&#46; The echocardiogram ruled out cardiac valve calcification&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">She received ibuprofen at regular doses&#44; physiotherapy and dry needling with mild improvement of her symptoms&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">Skeletal hyperostosis is rare in young patients&#46; According to the literature&#44; the development of isotretinoin-induced skeletal hyperostosis appears 3-5 years after the treatment&#44; with cervical spine and feet being the most frequent affected areas&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Although this side effect has been described by many authors since 1983&#44;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2-9</span></a> we observe that many patients are not aware of this complication&#46; Although our report is a single case&#44; correlates with literature&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">This case report has several limitations&#46; First of all&#44; we can&#769;t give precise information about the total dosis of isotretinoin&#46; Although the maximum cumulative dose of isotretinoin ranges from 120-150mg &#47;kg &#40;safety data sheet according&#41;&#44; relapses of severe acne vulgaris are very common&#44; and for decreasing relapse rates is common to receive higher doses of isotretinoin&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">10</span></a> Our message is that this side effect can occur in daily clinical practice&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Secondly&#44; we don&#769;t have a basal cervical x- ray to compare because she didn&#769;t have cervical pain at that time&#46; She began with cervical pain at 29 years old without any previous injury&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">We wonder if the cumulative doce should be reduced or the pacient should receive more concise information about long term complications&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0065" class="elsevierStylePara elsevierViewall">In young patients with diffuse idiopathic skeletal hiperostosis&#44; beside the cardiovascular comorbidities&#44; we should consider the use of isotretinoin and the cumulative doses&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Informed consent</span> was obtained from the patient for the publication of this report&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflict of interests</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We present the case of a 36-year-old woman with diffuse idiopathic skeletal hyperostosis especially at cervical spine since she was 29 years old&#46; The only relevant feature was the use of isotretinoin at regular doses in the past for severe acne&#46;</p></span>"
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Información del artículo
ISSN: 1699258X
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