Israel Medical Association Journal

A 70-year-old female with a 10-year history of dermatomyositis involving the skin, muscles, and gastrointestinal system was diagnosed based on proximal muscle weakness, typical dermatomyositis-specific rashes, elevated creatine kinase, and muscle biopsy findings consistent with dermatomyositis. Myositis-specific autoantibodies were negative.

The patient initially received treatment with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) but experienced gastrointestinal intolerance to both methotrexate and azathioprine. Subsequently, she was managed with intravenous immunoglobulin (IVIg) for 4 years; however, due to a relapse of muscle involvement, rituximab was initiated and has been administered for the past 3 years.

Over the last year, the patient achieved remission in muscle involvement but experienced worsening dermatomyositis-specific skin manifestations, including heliotrope rash, Gottron signs, and holster sign [Figure 1A], accompanied by severe pruritus that significantly impaired her quality of life. The Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI) activity score reached 17. Her skin condition remained refractory despite treatment with topical steroids and calcineurin inhibitors.

The prevalence of difficult-to-treat rheumatoid arthritis (D2T RA) varies between 5% and 25%, with females comprising the majority of patients and no difference in patient age between D2T and non-D2T RA cohorts. While several attempts to subclassify D2T RA patients into defined subgroups have been tried, the inclusion of an individual D2T RA patient to one of the predefined subgroups can be difficult or impossible as multiple factors are usually involved in the mechanisms of rheumatoid arthritis (RA) refractoriness, with the complex interplay of inflammatory, structural, social, and psychological factors being unique for each patient. More severe disease at presentation, including seropositivity and early erosion formation, and insufficiently aggressive initial treatment can both contribute to the eventual development of D2T RA. No single test or study can replace the holistic clinical approach to the diagnosis and understanding of the causation of D2T RA. Traditional in-depth clinical history and thorough clinical examination remain sine qua non in managing D2T RA patients. Multifaceted contributions of inflammatory and non-inflammatory components create the uniqueness of D2T RA and dictate a comprehensive approach to the management, including both pharmacologic and non-pharmacological therapeutic strategies. Mean annual total costs for D2T RA patients have been estimated as being about twice as high as that of patients with non-D2T RA.

A 90-year-old female with a medical history of untreated gout presented to the emergency department with acute low back pain. On physical examination, the area over the 4th lumbar spinous process was extremely tender. Serum C-reactive protein was 184 mg/L, and uric acid was 8.3 mg/dl.

Conventional [Figure 1A] and dual-energy computed tomography (DECT) [Figure 1B] studies of the lumbar spine showed multiple tophi-engulfing posterior vertebral structures of the involved vertebral unit, including the spinous and transverse processes and facet joints. This condition is schematically shown in Figure 1C with asterixis indicating tophi-induced erosion and osteolysis of the spinous process.

The patient was treated for a suspected acute gouty attack with prednisone and colchicine followed by allopurinol treatment with rapid and uneventful recovery.

Axial gout is an underdiagnosed and potentially curable cause of recurrent low back pain [1,2]. Referral to DECT should be considered in patients with uncontrolled gout and concurrent back pain.

A 52-year-old man with a history of gout presented to the emergency department with painful purulent ulcers on the left index finger. Serum C-reactive protein was elevated to 112 mg/L. Hand radiographs [Figure 1A] demonstrated almost complete osteolysis of the two distal phalanges of the involved finger (asterisk), with multiple typical gouty erosions with sclerotic margins and overhanging edges in a marginal and juxta-articular distribution (white arrows), and soft tissue tophi (black arrows). Osteomyelitis of the index finger was suspected, and the finger was amputated.

Idiopathic inflammatory myopathies (IIM) are a group of rare, autoimmune, systemic diseases with a large spectrum of clinical phenotypes. The diagnosis and management of myositis demand an integrated evaluation of different clinical, laboratory, and pathological findings in various organs. Recent developments in IIM research, especially in the serological testing and pathology fields, has led to a new classification and better recognition of patients with early or extra-muscular disease, with improvement in clinical care and prognosis.

Objectives: To compare the outcomes of two groups of CICF[1] patients who underwent two different treatment protocols.

Methods: The study cohort included 72 infants treated in our hospital from August 1998 to December 2002. Group 1 comprised 40 infants (61 clubfeet) who were treated by a traditional method (a modification of the Kite and Lovell technique), and group 2 consisted of 32 infants (48 clubfeet) who were treated with the Ponseti technique. Both groups were similar in age, gender and severity of the deformity (Dimeglio scoring system)

Results: After an average follow-up of 54.9 months (range 44–68), 35 (57%) clubfeet in group 1 required surgical intervention and 27 (44%) clubfeet had a residual deformity at last follow-up. In the Ponseti group, 45 (94%) clubfeet were fully corrected at last follow-up (average 29.2 months, range 16–45) while 3 (6%) clubfeet had residual deformity and required surgery. Tendo-Achilles tenotomy was performed with no complications in 47 clubfeet (in group 2) at an average age of 2.4 months (range 2–4 months).

Conclusions: Even after a relatively short follow‑up period, our success rate with the Ponseti approach already appears to be significantly higher and to bear fewer complications than the traditional treatment, in agreement with the results published by other medical centers. We now endorse the Ponseti technique of conservative manipulative treatment for congenital idiopathic clubfoot in our department.